Provider Demographics
NPI:1811396260
Name:OUT OF THIS WORLD DENTISTRY SJ PC
Entity Type:Organization
Organization Name:OUT OF THIS WORLD DENTISTRY SJ PC
Other - Org Name:OUT OF THIS WORLD SJ
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CORY
Authorized Official - Middle Name:
Authorized Official - Last Name:STARK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:801-260-0400
Mailing Address - Street 1:10426 S. 4000 W.
Mailing Address - Street 2:
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84009
Mailing Address - Country:US
Mailing Address - Phone:801-260-0400
Mailing Address - Fax:801-619-5399
Practice Address - Street 1:10426 S. 4000 W.
Practice Address - Street 2:
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84009
Practice Address - Country:US
Practice Address - Phone:801-260-0400
Practice Address - Fax:801-619-5399
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OUT OF THIS WORLD DENTISTRY PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-08-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty